1164488607 NPI number — MELISSA MITCHELL MCCORMICK M.D., F.A.A.P.

Table of content: MELISSA MITCHELL MCCORMICK M.D., F.A.A.P. (NPI 1164488607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164488607 NPI number — MELISSA MITCHELL MCCORMICK M.D., F.A.A.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCORMICK
Provider First Name:
MELISSA
Provider Middle Name:
MITCHELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D., F.A.A.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164488607
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
781 COLONIAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70806-6537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-490-5440
Provider Business Mailing Address Fax Number:
225-490-5489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7777 HENNESSY BLVD STE 7000
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70808-0307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-765-8829
Provider Business Practice Location Address Fax Number:
225-765-8283
Provider Enumeration Date:
04/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  201439 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1012343 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 157435201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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